registration form - little treasures daycare · registration form 450 blue mountain st. coquitlam...

Registration Form

450 Blue Mountain St. Coquitlam BC V3K 4K5 [email protected] 604-931-5593

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For office use only:

Date of Enrollment: _______________

Date of Resignation: _______________

Personal Information

Full Name of Child: ____________________________ Gender: __________________

Name Child Responds To:_______________________ Date of Birth: _______________

Address: ________________________________________________________________

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Phone Number: ___________________________

Mother’s Name: _______________________ Place of Employment: _______________

Home Phone: __________________________ Work Number: _____________________

Cell Number: ___________________

Address (if different from child’s): ___________________________________________

Father’s Name: _______________________ Place of Employment: ________________

Home Phone: _________________________ Work Number: _____________________

Cell Number: _______________________

Address (if different from child’s): ___________________________________________

Persons Authorized to Pick up Child (other than parents listed above)

1) Name: __________________________ Relationship: _________________________

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Home Number: ___________________ Work/Cell Number: ___________________





Emergency Contact (other than parents listed above)







Persons NOT Authorized to Pick Up Your Child





*Please note: If there is a Custody Agreement, please give details below. A copy of the custody order must be left with the centre’s manager.

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Emergency Health Information

Doctor’s Name/Clinic: _______________________ Phone Number: ________________

Address: ________________________________________________________________

Child’s Care Card Number: _________________________________________________

Dentist’s Name/Clinic: _______________________ Phone Number: _______________

Consent for Emergency Care

I ________________________ authorize the staff of Little Treasures Daycare to call a medical practitioner or ambulance in the case of accident or illness of my child, if the parents cannot be reached immediately.

Signature of Parent: ______________________________________ Date: ____________

Health Information (Please attach a separate sheet if necessary)

1) Regular medication (s) and reasons for (please list): ___________________________

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2) Allergies/Reactions and treatment (please list): _______________________________

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3) Any concerns/issues regarding your child’s health (seizures, asthma, vision, hearing, etc) (please list and describe):

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4) Any concerns regarding your child’s development (behaviour, speech, language, mobility, etc) (please list and describe):

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5) Please list any specific care instructions regarding #1-4: ________________________

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6) Other health care professionals involved in your child’s life (Occupational Therapist/Physical Treatment, etc) : __________________________________________

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Group Experiences

1) Has your child had previous Daycare experiences? If yes, how did he/she adapt?

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2) What is/are your child’s favorite toys/activities? ______________________________

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3) How does your child behave around other children (seeks others out, feels shy, etc)?

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Emotional

1) How does your child react when left with unfamiliar people and/or in unfamiliar situations? ______________________________________________________________

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2) What suggestions do you have that would help staff ease your child’s transition into the program? ____________________________________________________________

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Family Information

1) Please list the name(s) of the significant people in your child’s life (siblings, grandparents, etc): ________________________________________________________

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2) Primary language spoken at home: _____________________________________________________

3) Other languages spoken at home: _______________________________________________________

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Any Other Comments

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Signature of Parent Providing Information

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Parent Signature Date

Please Note: Fraser Health Authority Licensing Staff may review this information as per legislation.

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Little Treasures Employee Signature Date

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Photo Documentation Consent

Documenting the Centre’s activities is a part of our program. From time to time your child’s picture may be taken. Pictures taken will be used as displays in the classroom only.

I, ____________________________ understand that photos my be taken of my child as they take part in the daily activities at the daycare. I give the staff of Little Treasures Daycare permission to take photos and display in the classroom.

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Facebook Photo Documentation Consent

Little Treasures Daycare has its own Facebook page. This page is a place to communicate, see updates on the daycare, view pictures of your child’s day, and for people to see firsthand what Little Treasures is all about. To post any photos, Little Treasures Daycare needs your written consent to do so. Please fill out the appropriate section below.

I, __________________________ give Little Treasures Daycare permission to post photos of my child, __________________, on their Facebook page. I understand that these photos can be viewed by anyone who uses Facebook.

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OR

I, ______________________ do not give Little Treasures Daycare permission to post photos of my child, ____________________, on their Facebook page.

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registration form - little treasures daycare · registration form 450 blue mountain st. coquitlam...

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